Assessing the caring behaviors of critical care nurses - Sciedu Press

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Journal of Nursing Education and Practice

2018, Vol. 8, No. 10

ORIGINAL RESEARCH

Assessing the caring behaviors of critical care nurses Samah Anwar Shalaby∗1 , Nouf Fahad Janbi2 , Khairiah Khalid Mohammed2 , Kholud Mohammed Al-harthi2 1 2

Faculty of Nursing, Edmon Fremon St. Smouha, Alexandria, Egypt College of Nursing, King Saud Bin Abdul-Aziz University for Health Sciences, Saudi Arabia

Received: February 21, 2018 DOI: 10.5430/jnep.v8n10p77

Accepted: May 9, 2018 Online Published: May 21, 2018 URL: https://doi.org/10.5430/jnep.v8n10p77

A BSTRACT Objective: To assess the critical care nurses’ perception of their caring behaviors and factors affecting these behaviors. Methods: Participants of this descriptive correlational exploratory study included 277 critical care nurses selected conveniently from nurses worked in all critical care units in King Khalid Hospital, Jeddah. A self-reported questionnaire namely, “Critical Care Nurses Caring Behavior Perception” developed by the researchers after reviewing related literature was used to assess caring behaviors and their affecting factors as perceived by critical care nurses. Results: Seventy percent of the nurses aged between 31 to 50 years old and more than half of nurses had ICU experience ranged from 6 to 10 years, while two thirds of nurses had no previous training about caring behaviors. The study findings revealed that the majority of nurses had high scores of perceived caring behaviors, whereas the mean of their perception was 296.96 ± 18.32. There was a statistical significant positive relationship between nurses’ perception and their work circumstances, workload, job satisfaction, educational background and patient characteristics. Conclusions: It is important to consider critical units’ circumstances, nurses’ educational background, job satisfaction, as well as the nature of critically ill patients in order to promote nurses awareness and implementation of caring behaviors. Moreover, replication of the current study using qualitative approach for in-depth analysis of the impact of factors could affecting caring behaviors on nurses’ perception in various highly specialized critical care units.

Key Words: Critical care nurse, Caring behavior, Perception, Job satisfaction

1. I NTRODUCTION

may be words, thoughts, feelings, looks, actions, movement, gestures, body language, touch, acts, procedures and/or inforCaring has been described as the moral ideal of nursing and mation.[5] Therefore, caring entails personal, spiritual, moral the ‘heart’ of nursing.[1] Moreover, caring is the major intel- and to a certain degree the social involvement of the nurse, lectual, theoretical, heuristic, and core central to the practice as they commit to self, health team members and patients.[6] of the nursing profession.[2, 3] Despite the lack of a universal Watson (2009) theory shows that caring as the disciplinary definition for caring, it is known that in consist of two major foundation for nursing and caring science as an advanced elements of instrumental and expressive actions. The instruview of nursing and human sciences.[7] Watson articulated mental caring behaviors consist of the technical and physical ten carative factors which conceptually and practically illusbehaviors, and the expressive caring behaviors include the trate caring behaviors and these encompassed; formatting a psychosocial and emotional behaviors.[4] The caring behavhumanistic-altruistic system of values, strengthening hope iors include a wide variety of features and actions and these ∗ Correspondence: Samah Anwar Shalaby; Email: [email protected]; Address: Faculty of Nursing, Edmon Fremon St. Smouha, 21527, Alexandria, Egypt.

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and faith, cultivating self and/or others sensitivity, establishing a help-trust relationship, encouraging and accepting both positive and negative feelings expression, and utilizing a creative problem-solving caring process. The other factors articulated by Watson were providing a transpersonal teachinglearning, providing protective, corrective and/or supportive physical, social, spiritual, and mental environment, enhancing the gratification of human needs, and existentialphenomenological-spiritual forces.[7, 8]

Thus, nurses in a high technology environment may need more emphasis on advocacy roles and direct patients care.[21] Critical care nurses should maintain the balance between their technological and humanistic caring behaviors during the provision of individualized holistic patient care.[22] The other factors influencing critical care nurses’ caring behaviors include the nurse-patient ratio because this is critical to the establishment of a therapeutic nurse-patient relationship and helps the nurses to incorporate caring behaviors into comprehensive patient care.[23, 24] The critical care nurses’ In nursing practice the nurses’ caring behaviors may be work experience may also alter their caring behaviors and it influenced by numerous factors and these may include has been reported to have a positive correlation to the nurse’s the patient’s diagnosis, the type of institution, nurse’s age caring behavior.[25–28] and experience, self-respect, beliefs and workplace circumstances.[9, 10] Literature also shows that there are cultural The patient factors may also influence the nurses’ caring bedifferences in caring behaviors.[11] Other studies have re- haviors in critical care settings since in such settings nurses ported that the methods used in nurse’s assignment, lack are dealing with patients who have life threatening health of time and lack of caring support can significantly impact problems and dependent on advanced machines to support nurses’ caring behaviors.[12, 13] life as mechanical ventilators. Literature shows that experienced nurses caring for awaken mechanically ventilated Critical care nurses have a crucial role in providing direct patients find it to be more demanding but improved with individualized holistic care to meet the bio-psycho-social good opportunities for patient interactions, and to incorponeeds of critically ill patients and their families via the inrate patient needs and preferences.[29] tegration of caring processes. Available studies focusing on caring-oriented behaviors in critical care settings have Critical care nurses are significant members of the health described how critical nurses care for patients and their fami- care team and work in a complex environment. Critical care lies.[14, 15] However critical care nurses continue to be con- nurses confront multiple factors and situations that need them fronted with critically ill patients’ in pain, agony, facing to be aware of the need and role of caring behaviors.[30, 31] difficulty life support decisions and complicated therapeutic The current study was conducted to assess the critical care modalities.[16] Critical care nurses regularly face challenging nurses perception of their caring behaviors and factors affectethical dilemmas associated with patients’ care, advanced ing these behaviors. technology and tremendous changes in healthcare delivery, all of which necessitate the implementation of challenging Research questions decisions and new advocacy and caregiver responsibilities What are the caring behaviors perceived by critical care for the nurses.[17] nurses at King Khalid Hospital, Jeddah? Is there a relationNurses may be confronted with barriers in their ability to express caring in the critical care settings. The barriers can result into limited caring time for the patients and limited expression of caring behaviors, hence a difficulty in finding meaning or value in nurses’ work and subsequently a decline in job satisfaction.[18] The critical care units are usually considered to be highly stressful environments for the patients, their families and the health care providers. The stress in the critical care settings is extended by regular activities such as difficult decisions related to end-of-life care, strict standards for quality of patient care, inadequate opportunities for communication with relatives and high ICU nurse’s turnover rates.[19] The use of advanced technology has also tremendously limited the opportunities for improving caring communication, caring involvement, and caring provision in a safe effective and time saving manner.[20] 78

ship between the critical care nurses’ characteristics and their caring behavior perception? What are the factors affecting critical care nurses’ caring behaviors?

2. M ETHODOLOGY 2.1 Design A descriptive correlational design was used in this study. The study was conducted at King Khalid Hospital (KKH) which is 531-beds military hospital located in the Western Region of Saudi Arabia. The study focused on all critical care units in (KKH). The units where the data was collected were the following; four general intensive care units (ICU 1, ICU 2, ICU 3 and ICU 4), coronary care unit (CCU), acute coronary intensive care unit (ACICU), neonatal care unit (NICU), pediatric intensive care unit (PICU), burns care unit, and emergency department (ED). ISSN 1925-4040

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2.2 Study participants A convenience sampling technique was used to recruit the participants from each of the above critical care units. The total number of nurses working in critical care units was 277. The number of nurses working in the general ICUs, CCU, ACICU, NICU, Burns and emergency department was 58, 17, 25, 56, 16, 17 and 88, respectively. Regarding the inclusion criteria for participants, all critical care nurses in previously mentioned critical care units and willing to participate were included in the current study. 2.3 Study instrument A self-administered questionnaire consisting of three parts was used for data collection. The first part of the questionnaire had items collecting data about the nurses’ Demographic characteristics of age, gender, country of residence, educational level, past and current ICU work experience duration and setting/s, in addition to the current ICU environment. The second part of the questionnaire was the Modified version of Caring Behaviors Assessment Scale (CBAS). The CBAS is a standardized scale which was developed by Cronin and Harrison in 1988. The CBAS has 63 items categorized under 7 domains of caring behaviors based on Watson’s carative factors as follows; humanism/faith-hope/sensitivity (16 items), helping/trust (11 items), positive/negative feelings expression (4 items), teaching/learning (8 items), supportive/protective/corrective environment (12 items), human needs assistance (9 items) and existential/phenomological/spiritual forces (3 items). Whereas, its reliability of the CBAS using Chronbach’s alpha has been reported to range from 0.66 to 0.90 for the seven subscales.[17, 32] All items of the CBAS are rated on a 5-point Likert scale [1 for less important to 5 for most important]. The CBAS was slightly modified in the current study and the modifications included rephrasing of all 63 statements on the original tool so that each statement reflected the perception of the nurses and not that of the patients as indicated on original tool. The third section of questionnaire included the Factors of Nurses Caring Behaviors [FNCB] which was used to identify the factors perceived to affect the caring behaviors of critical care nurses. The FNCB was developed by the researcher after reviewing the related literature.[9, 10, 13] The FNCB consisted of 32 items about the possible factors which may affect the nurses caring behaviors. The factors were categorized under four categories of: work place circumstances (14 items), nurses’ workload, job satisfaction, and general interest in nursing profession (6 items), nurses’ educational background (4 items), and patients’ characteristics (8 items). All the items were rated on a 5-point Likert scale (1 for totally

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do not affect to 5 for completely affect). The questionnaire was tested for validity by asking the 5 experts in the field to assess relevancy and necessary modifications were done and after pilot the tool was tested. The Chronbach’s alpha for modified CBAS and the FNCB were .96 and .93 respectively. 2.4 Ethical considerations The study was reviewed and approved by the research and ethics committee of the college of nursing- Jeddah and KAIMRC. All the respondents were fully informed about the research purpose and the nature of the study. Also all respondents were required to indicate their willingness to participate in the study by signing a consent form. Participants were informed of their right to withdraw from the study at any time. The confidentiality of participants was mianatained by using code numbers rather than respondents’ real names during data collection and analysis. The questionnaire used for data collection were handled only by the research team. 2.5 Data analysis The data was analyzed using the Statistical package for social science software (SPSS version 20) software. Descriptive statistics were used to describe the sample and nurses’ caring behaviors. The correlaton statistics, t-test, and ANOVA were used to evalaute relationships between perceived caring behaviors and demographic characteristics. The significance level was set at p < .05.

3. R ESULTS 3.1 General description of socio-demographic and work related characteristics Table 1 shows the distribution of critical care nurses according to their socio-demographic and work related characteristics. The table revealed that the total number of nurses was 277. In relation to their age and gender, it was found that nurses’ age ranged between 20 and 60 years old, whereas above two thirds of the studied sample (70.8%) were in the age group between 31 to 50 years old and the majority of nurses (87%) were females. In relation to marital status, the result demonstrates that more than half of the studied sample (53.8%) was married. Concerning the nurses’ educational level, it was found that 63.9% of nurses had bachelor degree of nursing, while about one third of the nurses (36.1%) had diploma degree. Regarding nurses’ previous training or awareness about caring, around two thirds of nurses (65.3%) had no previous caring training.

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Table 1. Distribution of nurses according to their characteristics Characteristic

Age in years

Gender

Marital status

Level of professional education Received previous caring training

ICU Work experience in years

Unit of Work

Current unit workload (nurse to patient ratio)

Category

No. (n = 277)

(100%)

20-30 31-40 41-50 51-60 Male Female Single Married Divorced Diploma Bachelor No Yes 10 General ICU CCU ACICU NICU PICU Burns Emergency 1:1 1:2 1:4

12 88 108 69 36 241 105 149 23 100 177 181 96 22 50 98 56 58 17 25 56 16 17 88 112 77 88

4.3% 31.8% 39.0% 24.9% 13% 87% 37.9% 53.8% 8.3% 36.1% 63.9% 65.3% 34.7% 7.9% 18.1% 53.8% 20.2% 21% 6.1% 9% 20.2% 5.8% 6.1% 31.8% 40.4% 27.8% 31.8%

Regarding to ICU experience duration, it was found that the majority of nurses (71.9%) had more than one year up to ten years of experience, compared to only (7.9%) had less than one year experience, while around one fifth of nurses (20.2%) had more than10 years of ICU experience.

The highest ranking of the NCBs categories was related to Human/ Needs assistance presented by 95.9% mean score percent and mean ± SD (43.16 ± 2.99), followed by the environment presented by 95.2% mean score percent and mean ± SD (57.12 ± 3.67). While, the least reported NCBs category mean was related to Teaching/Learning presented In relation to the current workplace, it was found that around by 92.1% mean score percent and mean ± SD (36.86 ± one third of nurses (31.8%) worked at emergency depart3.86). ment (ER), one-fifth (21%) of nurses worked in General ICU similar to the percentage of nurses who worked in NICU. Regarding the mean score and standard deviation of the While the lower percentage (less than 10%) of nurses worked factors affecting NCBs and related categories, Factors affectin each of other critical units included; CCU, ACICU, and ing NCBs scores ranged between 54 and 160 represented PICU. Regarding the current unit workload, it was found that by mean score (134.72 ± 20.8). The highest factor affectaround two third of nurses (68.2%) were assigned to one or ing NCBs was workload and job satisfaction represented by two patients expect for ER nurses (31.8%) were assigned to 90.2% mean score percent and mean ± SD (27.05 ± 4.90), four patients. followed by the workplace circumstances represented by 85.7% mean score percent and mean ± SD (59.97 ± 10.14). 3.2 Perceived nurses caring behaviors While, the least reported factor affecting NCBs was patient Table 2 shows the mean score and standard deviation of the characteristics represented by 72.7% mean score percent and NCBs and related categories. (NCBs) scores ranged between mean ± SD (29.06 ± 8.77). For additional information (see 189 and 315 represented by mean score (296.96 ± 18.32). Table 2). 80

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Table 2. Description of nurses’ perceived caring behaviors and affecting factors Item

Caring Behaviors

Factors affecting

Categories

Min

Max

Mean± SD

Ranking (%)

Humanism/Faith/Hope

48

80

75.19 ± 5.09

93.9

Helping/Trust

33

55

51.99 ± 4.42

94.5

Feelings expression

12

20

18.61 ± 1.96

93.1

Teaching/Learning

8

40

36.86 ± 3.86

92.1

Environment

36

60

57.12 ± 3.67

95.2

Human/Needs Assistance

27

45

43.16 ± 2.99

95.9

Spiritual Forces

8

15

14.04 ± 1.43

93.6

Workplace circumstances

28

70

59.97 ± 10.14

85.7

Workload/job satisfaction

7

30

27.05 ± 4.90

90.2

Educational background

11

20

16.71 ± 2.07

83.6

Patient characteristics

8

40

29.06 ± 8.77

72.7

Table 3 exhibits scores of the perceived importance of perceived NCBs, it reveals that the majority of nurses (96.8%) perceived high importance level of caring behaviors. Whereas, only 3.2% of nurses perceived low importance of their caring behaviors.

Also it displays scores of the perceived effectiveness of factors affecting NCBs, the table reveals that the majority of nurses (79.8%) perceived high effectiveness level of factors affecting NCBs. Whereas, only 20.2% of nurses perceived low effectiveness level of their factors affecting caring behaviors.

Table 3. Nurses perceived importance of caring behaviors and the effect of factors on their caring behaviors Factor Perceived NCBs scores Factor affecting NCBs

Rating

No of nurses

Min

Max

Low important

9

3.2

189

251

High important

268

96.8

252

315

Low effective

56

20.2

54

127

High effective

221

79.8

128

160

3.3 Relationship between nurses’ characteristics and their perceived caring behaviors and affecting factors Table 4 exhibits the relationship between NCBs and factors affecting NCBs, it was found that there is a positive significant correlation between all categories of NCBs and factors affecting their caring behaviors whereas, p significant at .05 level except for Helping/Trust relationship category of NCBs which has significant correlation only with educational background and workload/job satisfaction at .05 level. Table 5 displays the relation between nurses’ sociodemographic/work related characteristics with their perceived caring behaviors categories and factors affecting their caring behaviors. From this table it was seen that, there is no significant relationship between nurses caring behaviors with their age, gender, and marital status. On the other hand, a significant relationship was found between NCBs and their experience and workload where p = .000 for all caring categories. Also, there is a positive significant correlation Published by Sciedu Press

Percent (%)

Mean ± SD 296.96 ± 18.32 143.78 ± 8.66

between nurses previous training only with Helping/Trust, and Environment caring categories where p = .031 and .018 respectively. In addition, there is a positive significant correlation between nurses educational level only with feelings expression, Environment and Human/Needs assistance caring categories where p = .023, .004 and p = .004 respectively. Regarding the factors affecting nurses’ caring behaviors, it was found that, there is no significant relationship between factors affecting NCBs and nurses’ age, marital status, and educational level. On the other hand, a significant relationship was found between factors affecting NCBs and nurses’ experience and workload where p = .000 for all factors categories. Also, there are significant relationship between nurses’ gender with work place circumstances and workload/ job satisfaction factors where p = .004 and .040 respectively. In addition, there is a positive significant correlation between nurses previous training with educational background, and workload/job satisfaction factors where p = .041 and p = .047 respectively. 81

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Table 4. Correlations between perceived nurses’ caring behaviors (PNCBs) and factors affecting their caring behaviors Perceived Nurses Caring Behaviors NCBs Factors

Humanism Faith/Hope

Helping /trust

Feelings expression

Teaching Learning

Environment

Human Needs Assistance

Spiritual Forces

Total PNCBs

r

.305

.065

.253

.381

.352

.126

.323

.324

p

.000**

.282

.000**

.000**

.000**

.036*

.000**

.000**

Educational background

r

.433

.449

.407

.286

.517

.251

.409

.509

p

.000**

.000**

.000**

.000**

.000**

.000**

.000**

.000**

Patient characteristics

r

.211

.028

.164

.300

.198

.119

.270

.226

p

.000**

.648

.006**

.000**

.001**

.049*

.000**

.000**

Workload/ job satisfaction

r

.226

.122

.191

.339

.234

.307

.258

0.302

p

.000**

.042*

.001**

.000**

.000**

.000**

.000**

.000**

Work place circumstances

Note. r: Pearson coefficient, * p ≤ .05 at 5% level denotes a significant difference, ** p ≤ .01 at 1% level denotes a highly significant difference.

Table 5. Relationship between demographic characteristics with nurses’ perceived caring behaviors and the factors affecting their caring behaviors Nurses’ Characteristics Item

Caring Behaviors

Categories

Humanism/ Faith/Hope Helping/ Trust Feelings expression Teaching/ Learning Environment Human/Needs Assistance Spiritual Forces

Factors affecting

Workplace circumstance Educational background Patient characteristic Workload/job satisfaction

Age

Gender

t (p) .003 .965 .053 .377 .057 .344 -.083 .166 .050 .407 .100 .098 .070 .245 -.037 .542 .021 .724 -.054 .366 -.082 .174

t (p) -.001 .999 1.032 .303 .289 .773 -.644 .520 .862 .389 .979 .329 1.320 .188 2.892 .004** -.409 .386 -.653 -.514 2.060 .040*

Marital Status F (p) 1.028 .359 2.521 .082 1.845 .160 .163 .850 1.033 .357 1.174 .311 2.822 .061 .230 .795 1.810 .166 .394 .675 .323 .725

Education level F (p) 1.429 .241 2.807 .062 3.814 .023* 1.751 .176 5.743 .004** 5.523 .004** .446 .641 .582 .559 .195 .823 .171 .843 2.290 .103

Previous training t (p) -1.000 .318 -2.169 .031* -1.869 .063 -.932 .352 -2.379 .018* -1.824 .069 -1.876 .062 -.864 .388 -2.051 .041* -1.537 .126 -1.998 .047*

Experience

Workload

F (p) 3.427 .001** 7.233 .000** 5.226 .000** 9.214 .000** 9.394 .000** 4.270 .000** 8.229 .000** 16.570 .000** 6.277 .000** 9.237 .000** 18.877 .000**

F (p) 5.793 .003** 18.858 .000** 12.497 .000** 8.849 .000** 28.463 .000** 12.506 .000** 25.470 .000** 9.256 .000** 12.660 .000** 11.017 .000** 17.028 .000**

Note. p value for nurse’s t-test; Fp: p value for F-test (analysis of variance [ANOVA]). * p ≤ .05 at 5% level denotes a significant difference; ** p ≤ .01 at 1% level denotes a highly significant difference.

4. D ISCUSSION

families. Therefore, the current study aimed to explore the critical care nurses perception of their caring behaviors as Critical care nurses provide a comprehensive care to meet well as the factors affecting their caring behaviors, and pinthe bio-psycho-social needs of critically ill patients and their 82

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point the relationship between the nurses’ perception and were related to Teaching/Learning on the cognitive domain their socio-demographic and work related characteristics in of caring.[25] King Khalid Hospital (KKH). Concerning factors affecting the critical care nurses caring The current study findings revealed that the majority of behaviors, the current study findings entitled; workload and nurses’ age ranged between 31 to 50 years old which may be job satisfaction, workplace circumstances, educational backdue to the hospital attitude to hire highly experienced nurses ground, as well as the nature of patients’ characteristic, as the in the critical care units. Surprisingly, the majority of nurses overall categorical factors that reported as highly effective had no previous training regarding caring behaviors in rela- on NCBs by eighty percent of nurses. Furthermore, all these tion to their higher perception of caring behaviors, which can factors encountered tremendous challenges for nurses and be as a result of hospital caring policy and attitude. Moreover, influence their perception of caring behaviors.[9] the current study findings revealed that the emergency nurses’ Furthermore, the current research findings showed that the workload was one to four because of high turnover rate in workload and job satisfaction was ranked by nurses as the the nurse emergency department while the nurse patient ratio first categorical factor affecting NCBs. This is congruence was one to one or two patients in other critical care units. with Elbahnasawy et al. (2016) who found that above half of Apparently the majority of critical care nurses in KKH per- nurses reported that heavy workload act as a barrier against ceived their caring behaviors as highly important specifically Watson theory application.[33] Which is supported by other human needs assistance which was rated by nurses as the study findings which demonstrated that heavy workload by first most important caring behaviors category which con- inadequate nurse-to-patient ratio was perceived as the greatfirmed the significance of physiological aspect of care and est barriers to care provision.[13, 30] Furthermore, Salimi and assistance of critically ill patients for gratification of their Azimpour (2013) presented job satisfaction as the highest physiological needs as the first priority based on Maslow score affecting caring behavior.[9] hierarchy of human needs. Which is in line with other reMoreover, the current study findings revealed no significant searchers who reported that human needs assistance caterelationship between NCBs with their age, gender, and marigory as the most important caring behaviors as perceived tal status. This is similar to another study about cancer nurses’ by nurses.[33, 34] Similarly to Pajnkihar et al. (2017) results perceptions of caring behaviors.[38] While the current study which entitled the carative factor needs as the highest caring found a positive correlation between nurses’ previous trainbehaviors as perceived by nurses.[35] This is contradicting ing and workload/job satisfaction with their environment with O’Connell and Landers (2008) who reported that the caring categories which is in line with Shen and coauthors’ highest score of nurses caring behaviors was related to hufindings whereas nurses’ quality of care was affected by the manism/faith/hope/sensitivity domain of caring.[22] hospital environment.[39] On the other hand, patients’ charFurthermore, the current study findings also revealed that the acteristic was the least effective factor on NCBs as reported supportive/protective/corrective environment items ranked by nurses. This is in line with other study[9] which reported as the second highly important caring behaviors by nurses. the patients’ gender and age represented by the lowest mean This may be influenced by nurses’ awareness with the vulner- score among the factors affecting caring behaviors, which ability nature of the critically ill patients and the importance may be rationalized by the nurses’ fair and equal approach in of maintaining patients’ safety and protection in highly so- caring provision regardless the patients’ characteristics and phisticated, hostile and stressful ICU environment.[19, 36] conditions. On the other hand, the current study findings revealed that the Teaching/Learning items ranked as the least important caring behaviors by nurses. Which may be rationalized due to limitation in patients’ communication by intubation, mechanical ventilation and alteration of patients’ level of consciousness which are common problem within the critically ill patients society,[37] in addition to low impact of the effect of the cognitive domain of care from the nurses’ perspective, especially the majority of these nurses did not receive any previous training or awareness regarding the caring behaviors. This was incongruent with the findings of other authors who reported that the highest perceived nurses caring behaviors Published by Sciedu Press

5. C ONCLUSIONS The current study offered an evidence that the critical care nurses in (KKH), Jeddah had high awareness regarding all categories of caring behaviors toward the critically ill patients include: humanism/faith/hope, and sensitivity, Helping/trust, expression of positive and negative feelings, teaching/learning, supportive/protective/corrective environment, human needs assistance in addition to existential/phenomological and spiritual forces. However, nurses highly emphasized on the importance of caring behaviors belong to human needs assistance and support83

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ive/protective/corrective environment categories of all caring a wide diversity of nurses’ characteristics and caring cultures. behaviors, while teaching/learning did not have the same higher influence on nurses’ perceptions of carative factors. ACKNOWLEDGEMENTS This study was supported by King Saud Bin Abdul-Aziz UniDifferences in health care institutions probably, relate to dif- versity, college of nursing research unit. The authors welling ferent caring cultures and nurses’ workload. Therefore, it to acknowledge ICUs’ nurses in King Khalid Hospitalis important to consider ICU circumstances, nurses’ educa- Jeddah for their tremendous cooperation and support during tional background, job satisfaction, as well as the nature of this study. critically ill patients in order to promote nurses awareness and implementation of caring behaviors. Moreover, replica- C ONFLICTS OF I NTEREST D ISCLOSURE tion of the current study using qualitative design to pinpoint The authors declared no conflicts of interest. the differences in various hospital settings and correlate with

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